Restrictive migration policies and their impact on HIV prevention, care and treatment services

Migration policies have a significant impact on population health, particularly for individuals living with human immunodeficiency virus (HIV). These policies not only determine who is allowed to enter a country but also influence which immigrants can access services provided by the government. Some countries continue to impose restrictions on HIV-positive individuals, justifying these measures as necessary to protect public health and mitigate healthcare and economic concerns. However, these restrictions lack a valid public health rationale. Due to social, economic and political constraints, restrictive migration laws hinder access to HIV prevention, care and treatment services for immigrants living with HIV. Immigrants face numerous challenges in accessing medication, adhering to treatment regimens and benefitting from HIV preventive efforts. This situation increases the risk of HIV infection and adverse health outcomes due to limited access to preventive programmes, social stigma and engagement in risky behaviours. Additionally, these restrictive migration rules negatively affect immigrants’ mental health. To improve the health of both immigrants and host communities, inclusive and evidence-based migration policies that address healthcare through public health and human rights lenses are required.

HIV positive, prohibiting their entry or ongoing stay on the basis of threats of international spread of the virus [3].These restrictions are justified by governments as measures to safeguard public health and prevent perceived burdens on healthcare and economic resources stemming from the presence of HIV-positive non-citizens.However, it is important to note that these justifications lack valid public health rationale [3], thus hampering health outcomes.
Due to a paucity of data, it is difficult to determine the exact extent to which migration affects the overall burden of HIV/acquired immunodeficiency syndrome (AIDS) globally.However, strong evidence indicates that migrants from countries with widespread HIV epidemics, notably those from sub-Saharan Africa, are disproportionately impacted by HIV compared with the local populations of host countries [4].Conversely, the proportion of HIV/AIDS infections among migrants is generally lower than in their countries of origin, which can be explained by the "healthy immigrant effect" [4].
Moreover, disparities in healthcare access and structural discrimination contribute to the significant gap in the number of migrants living with HIV who can access treatment, despite global Antiretroviral therapy (ART) coverage reaching 76% [5].In Western Europe, the proportion of migrants among those infected with HIV ranged from 20% to 40% [4].HIV prevalence among migrant women aged 25-29 in KwaZulu-Natal, South Africa, has been shown to be as high as 63% [6].Additionally, in South-East Asia, HIV prevalence among migrants to Thailand from neighbouring countries is up to four times higher than in the overall population [6].
Exploring the implications of those migration policies that restrict access to HIV prevention, care and treatment services, particularly for immigrants living with HIV, is essential to inform health policymakers and for advocacy.This article aims to provide a snapshot into these policies and their potential impact on the health and wellbeing of affected individuals in order to serve as a groundwork for further research on the need for more inclusive and evidence-based approaches to migration policies that prioritize both public health and human rights considerations.

Current situation of restrictive migration policies and HIV services
Historically, numerous countries have implemented stringent immigration regulations specifically targeting individuals who are HIV positive [1].These policies were initially rooted in misunderstandings and fears surrounding HIV transmission.Joint United Nations Programme on HIV/AIDS (UNAIDS) has played a pivotal role in advocating for the elimination of travel restrictions related to HIV, asserting that such restrictions are discriminatory and lack a scientific basis and providing guidance to countries on developing inclusive migration policies [3].As global perspectives on individuals living with HIV have evolved and medical knowledge and treatments have advanced, some countries have recognized the discriminatory nature of these policies, thereby lifting or easing these restrictions [3].
While 203 jurisdictions worldwide, which includes countries, territories and areas, have eliminated HIVrelated restrictions on entry, stay and residence, 48 jurisdictions still maintain various forms of restrictive migration policies for immigrants living with HIV [3].Some jurisdictions deport non-nationals solely on the basis of their HIV status (Table 1), while others deny both short-and long-term stays on the same grounds (Table 2).Certain jurisdictions may require HIV testing for specific types of permits (Table 3).Unfortunately, when HIV testing is conducted within the context of migration, established global protocols regarding informed consent, confidentiality and counselling are not consistently implemented [7].This practice overlooks the economic benefits of migration and the sustained productivity of individuals living with HIV, who can benefit from improved treatments during extended stays.Denying entry or deporting someone solely on the basis of their HIV status is considered discriminatory and unjust.

Impact of restrictive migration policies on access to HIV prevention, care and treatment services
Immigrating to a foreign country, territory or area presents many challenges.Immigrants often face a multitude of social, financial, legal and political barriers that hinder their access to public services, including healthcare [8].These healthcare services are essential; however, immigrants living with HIV encounter significant difficulties in accessing treatment, adhering to treatment regimens and benefitting from HIV prevention measures such as regular testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) due to restrictive policies in the host country, territory or area [9].
For instance, all long-term visitors to Canada are assessed on the basis of the "excessive demand" they may place on the Canadian healthcare system [10].A yearly cost exceeding CA$24,057 is deemed "excessive", yet many publicly supported HIV drugs cost less than this amount [10].Consequently, a positive HIV test result might make it difficult for a person to permanently immigrate to Canada.Although Canadian laws and policies do not explicitly mention HIV, they do allow for an application to be denied on the basis of medical inadmissibility.Similarly, work permits in St Vincent and the Grenadines are not renewed if an HIV test is positive, and HIV-positive foreigners have no access to treatment or assistance [10].
The lack of access to essential healthcare services is appalling as the immigration process exposes individuals to an increased risk of acquiring HIV infection, compounded by inaccessibility to effective HIV prevention techniques, including early diagnosis through testing, and individuals are less likely to receive treatment [5,8].This results in a higher risk of HIV-related mortality among immigrants than a local population [9].In addition to limited availability of HIV prevention services, other factors heightening the vulnerability of immigrants to HIV infection in host countries can be attributed to various factors, such as social stigma and engagement in risky behaviours [5].
The unavailability of healthcare services for immigrants is further exacerbated by policies that require proof of citizenship or residency [4].It is unsurprising that undocumented immigrants living with HIV avoid seeking healthcare services for fear of detention, deportation or punishment [4].In Switzerland, for example, undocumented migrants, like citizens, must obtain expensive private health insurance to access basic healthcare, costing more than €250 a month [4].Failure to pay premiums  Papua New Guinea -People over 16 years may be required to take an HIV test for entry permit application -An HIV test may be required for a long-term visa (more than 6 months) or for residence permits Entry permit applications may be rejected due to a positive HIV status -Possible denial of entry permit and long-term visa on time results in judicial complaints, and obtaining insurance requires verification of identification and residency.When migrants acquire health insurance, their situation may be reported to immigration services.In the Russian Federation, undocumented migrants have no access to healthcare, which is dependent on the social insurance system [4].This fear prevents them from seeking HIV testing, treatment and care, significantly increasing the risk of HIV transmission and worsening health outcomes.Additional factors hindering access to HIV prevention and treatment services include provider discrimination, racism, low HIV risk perception, language barriers and negative perceptions [11], which are aggravated by migration policies that discriminate against immigrants living with HIV [12].
Furthermore, policies that demand upfront payment for healthcare services can be a significant barrier to healthcare for immigrants who lack financial means [13] and experience socio-economic disadvantages compared with the general population [14] due to limited access to well-compensated employment opportunities.Lower socio-economic status, whether combined with migration status or not, contributes to health disparities and inferior health outcomes [15].This situation can impact the ability of immigrants to access HIV prevention, care and treatment services.
Restrictive migration policies can also have an indirect impact on the mental health of immigrants [16], which can subsequently affect HIV prevention and care.This was documented in another study, proving that immigrants are subjected to restrictive integration policies and more prone to negative effects on their mental health, self-rated health, utilization of healthcare services and overall mortality rates [17].

Recommendations and action
Efforts to improve access to HIV services for immigrants are crucial in achieving Sustainable Development Goal 3, which aims to end the AIDS epidemic by 2030.The World Health Organization (WHO) recognizes that access to the highest attainable standard of health, including HIV prevention, care and treatment services, is a fundamental right of every human being [17].To achieve this goal, governments of countries with restrictive policies, civil society organizations (CSOs) and international partners should collaborate and take the following actions:

Government policy evaluation
Governments should conduct a thorough assessment of their migration policies to align with international human rights standards and evidence-based public health measures.This evaluation should ensure that immigrants have equal access to healthcare, remove barriers to HIV prevention, care and treatment services, and address issues related to immigration status, socio-economic status, sexual orientation and gender identity.It is crucial ensure that policies are inclusive and prioritize the consideration of immigrants for employment opportunities, thereby improving their socio-economic status.Specific measures may include removing HIV/AIDS from the list of diseases requiring proof for admission, immigration, employment and reintegration.Governments can also establish discreet health posts that offer specialized care to people living with HIV and those at higher risk of contracting HIV, provide training for healthcare practitioners on migrant health issues, expand outreach programmes targeting vulnerable populations, increase funding for HIV prevention and care activities for immigrants, and facilitate partnerships between governmental and non-governmental organizations to improve service provision for migrant populations.

Advocacy by CSOs
CSOs should engage in evidence-based advocacy efforts to drive the reform of migration policies that impede the availability of HIV prevention, care and treatment services.These efforts should focus on not only increasing public awareness of the adverse effects of restrictive policies on HIV services but also tackling stigma or any form of discrimination through awareness campaigns and outreach programmes.CSOs should advocate for policy alternatives that promote the rights and wellbeing of immigrants, participate in dialogues with policymakers, and collaborate with relevant stakeholders.Research and data collection should also be prioritized by CSOs to produce robust evidence regarding the impact of migration policies on HIV prevention, care and treatment outcomes.

Support from international organizations
International organizations should advocate for more inclusive and rights-based migration policies in destination countries, territories or areas.Jurisdictions with restrictive migration policies can benefit from technical support and capacity development provided by international organizations.This may include cultural competence training for healthcare personnel to ensure they understand the unique needs of immigrant populations, establishment of referral networks to facilitate access to comprehensive healthcare services and ensuring that healthcare services are accessible to multilingual and immigrant communities.International organizations should also facilitate collaboration between governments, CSOs and affected communities to address the challenges faced by immigrants in accessing HIV services.

Research and data collection
Research plays a crucial role in generating evidence to inform policy and practice related to people living with HIV who are migrants.Additionally, longitudinal studies tracking health outcomes and the long-term impacts of these migration policies can highlight the benefits of inclusive policies, making a strong case for policy reform.Collaboration between academia, government bodies, CSOs and affected communities is vital to ensure that research is relevant and impactful.Engaging with communities provides essential perspectives, ensuring studies address real-world challenges and needs.This collaborative approach builds trust and ensures research findings effectively advocate for necessary changes.By addressing these areas, stakeholders can create an inclusive environment where immigrants, especially those living with HIV, have equitable access to essential health services, contributing to the global effort to end the AIDS epidemic by 2030.

Conclusion
Migration policies affect immigrants' HIV prevention and care services; hence, a more integrated strategy is required to address these challenges.The exclusion of immigrants from these services hinders worldwide HIV epidemic efforts and promotes HIV transmission among this community.Restrictive and criminalizing laws might discourage immigrants from obtaining assistance.Inclusive migration policies, universal healthcare, outreach activities and a multisectoral approach to HIV prevention and care will enhance immigrants' and host populations' health.Countries may enhance immigrants' health and create a more welcoming atmosphere by following these policy ideas.

Table 1
Countries that deport non-nationals on the

basis of HIV Country Policy Outcome (for foreign PLHIVs)
Tests performed outside of the UAE are not accepted for this purpose -PLHIVs are not allowed to enter UAE with ARVs and may be detained and face scrutiny; deportation -For work permits, an initial HIV test is mandatory in the home country and repeated in Malaysia, with annual retesting required -Denial of permit and possible deportation once HIV is diagnosed in foreigners on the Temporary Employment Visitor Pass Oman -Tourists are not required to test for HIV -HIV test results are mandatory for work or residency permits and immigrants who are positive are required to return to their country of origin -Visitors are allowed to bring their ARVs if positive -Foreign PLHIVs are usually expelled Qatar -HIV test is not required for passengers in transit and tourists (< 1 month stay) -Residency and employment applications require HIV test results, and positive results result in denial and deportation -Denial of residency and employment permits; possible deportation if found to be HIV positive Russian Federation -No test required for persons staying for less than 90 days -Stays of more than 90 days (for work or study) as well as multiple entry visas require a negative HIV test result to be approved -Quarterly HIV testing mandated for foreigners residing in the country since 29 December 2021 -Denial of permits and deportation Saudi Arabia -Residence and work permit applicants are required to take an HIV test, and permits are not granted if the test returns positive -Denial of permits and probable deportation Singapore -HIV test is not required for tourist or business visa applicants up to 90 days -HIV test is mandatory for all stays beyond 90 days for which a positive test results in rejection -Entry ban for HIV-positive long-term visitors, possible deportation; HIV-positive foreign spouses are allowed to remain Solomon Islands -HIV test is mandatory for visitors staying for more than 90 days -Possible denial of permit and deportation Sudan -No restriction or test requirements for short-term stays (< 3 months) -Applicants of work or residence visas need to submit a negative HIV test result before obtaining such -Denial of permit and possible deportation Table 1 (continued) Country Policy Outcome (for foreign PLHIVs) Syrian Arab Republic -Tourist visa applications typically do not require HIV testing, including 6-month multientry visas -Foreigners aged 15-60 must undergo HIV testing when applying for a residence permit, which is granted only if the result is negative -Foreigners intending to marry Syrian nationals must undergo HIV testing -Denial of residence or long-stay permit, deportation Turkmenistan -No restriction or test requirements for short-stay visas, single or multiple entry, up to 12 months -Residency permit for work or study requires an HIV test and a positive HIV test result may lead to deportation -Denial of permits and possible deportation United Arab Emirates -No restriction or test requirements for short-stay travellers, up to 60 days.--HIV tests are required for foreigners who apply to obtain or renew work and residence permit which is denied, and foreigner is deported once a positive result is returned.

Table 2
Countries that may deny both short-and long-term stays on the basis of HIV Source: Still not welcome -HIV-related travel restrictions Available on https:// www.unaids.org/ sites/ defau lt/ files/ media_ asset/ hiv-relat ed-travel-restr ictio ns-expla iner_ en.pdf -Short-term stay up to 30 days does not require HIV result -All stay for more than 30 days regardless of reason (tourism, work, study, residence) must submit an HIV test result.A positive HIV test results in denial of permit -Denial of long-term stay permits Mauritius -Temporary visitors are not required to submit HIV test result -Application for work and residence permits require an HIV test result.A positive HIV test results in denial of residence permit -Denial of work and long-term stay permits

Table 3
Countries that may require HIV testing for certain types of permits

Table 3
(continued) Addressing the significant paucity of data in this area, academic communities must conduct comprehensive research to provide critical insights into health disparities among immigrant populations.Evaluating the effectiveness of various interventions aimed at improving HIV prevention, care and treatment for immigrants is essential.By determining what strategies work best in different contexts, researchers can design and implement more effective health interventions tailored to the unique needs of immigrant communities.